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Tεύχος 31 | Σεπτέμβριος - Οκτώβριος 2024
yes, I would open. But I would also call for a trauma or general surgeon in order to cover all my bases and to make sure that what was going to happen to the patient would be the best possible outcome.
Asking the question another way, if you said to me: " In my career as a resident, I have 100 patients who need a nephrectomy. Should I do 50 of them open and 50 of them robotically or laparoscopically?". I would answer: "You really need to become very proficient in the laparoscopic/robotic procedure and so you probably want to focus your energies there, such that at least 90% of your cases are laparoscopic/robotic". Do I think you should learn the basic techniques on how to open the abdomen, so if you have to, you can get in there quickly? My answer is yes, you should.
T.S.: What were your thoughts when the first robotic system was released?
Prof. Ralph V. Clayman: I thought it was fabulous. What it did is to take the laparoscopic platform and put it on a different level. Nonrobotic laparoscopy is hard on your body; indeed, when I was in St. Louis, we bought a hot tub for our backyard at home, because I would come home after some of the laparoscopic procedures and just be aching all over. Jens Rassweiler actually developed a motorized floating chair assembly so he could operate more easilylaparoscopically. ThenoutcomestheIntuitive robot, and now you could sit at a console, rest your head, relax your arms and be completely comfortable while working with instruments that moved intuitively and gave you six degrees of freedom instead of just four and provided a three-dimensional view of the field instead of two dimensional. You were able to suture far better than you could ever suture with typical laparoscopic instruments.
The laparoscopic robot also opened the door for the entire specialty of Urology to come into the realm of less invasive surgery. Case in point, laparoscopic prostatectomy was incredibly difficult to do. Only a handful of people in the world were doing it. It never captured the market, it never accounted for more than 3% of all the radical prostatectomies done in the world. Enter the robot and all of a sudden open and laparoscopic prostatectomy are dead. The beauty of the robot is that the open surgeon can transfer their skills to the robot almost seamlessly. Tom Ahlering here at UCI is a perfect example of that statement.
His superb open skills translated directly to the robot. What did Tom have to say about the robot, after his first case that took twice as long as his usual open prostatectomy? He just said simply: " I've never seen the anatomy as well as I saw it today". Game over! The person who got punished with the robot was the laparoscopic surgeon, as that person had learned to work in a counterintuitive manner, in a two- dimensional world. It took the trained laparoscopic surgeon more effort to adapt to the robot, than it took the open surgeon to adapt to the robot, in my opinion. This is progress. If you're not willing to accept the fact that the wonderful things that you've invented or created during your life are merely stepping stones to other new wonderful things, then you are an impediment to progress? This is the biggest problem. The pioneers of the past are oftentimes the biggest obstacles to the innovations of the future.
I see Academia as though it were a vast lily pond. You go from one side of the pond, from lily to lily to lily, in order to get to the other side of the pond. If you land on a lily pad that you particularly like and start to build a castle on it, the lily pad and you both sink. That's what happens when a pioneer gets overly enamored with the one discovery they may have had in their life. In Academia, you have to keep moving forward. If you're not moving forward, then remove yourself from the pond and make room for somebody else.
F.N.: Minimally-invasive surgery and the management of stone disease involve numerous technological innovations. How important
is the collaboration between urologists and other scientific fields, such as engineering, for advancing and improving these technologies.
Prof. Ralph V. Clayman: It's essential! The name of the game is teamwork. You want to draw bigger circles. The more people of diverse backgrounds that you bring into your laboratory, the greater are the chances of your success. Working with engineers is fabulous. They bring a whole different perspective to the problem. A perfect example is the ureteral access sheath. Some people hate them, some people like them. We happen to like them. I like the idea that I can go up the ureter multiple times, back and forth, pulling out stone fragments and getting my patient to be as stone-free as possible. I don't like "dusting and running", because you leave the patient with lots
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